Sullivan N 1007 Convenience Store Remodel & Add
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A PERti11T1
BUILDING PERivIt'i i-if I'L1CA1'ION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY TH05E PARTS 0F THE FORM YOU UNDERSTANQ
COMi'LETE IN INK -L---.~~ ~
(Please return this original and your buiiding ptans to ihe Department ot 8ufldinq and Safely)
SHADED AREAS ARE FOR DEPAATMENTAL USE ' "ectNumoor '
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G OEPARTNiENTAL REVlEW
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Approved qpproval Nold
. EnvlronmeMal Health Appllcatlon p
79 W 1101 College ~
• Room 200 ,
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~ Plennine/Zoning
~ N 721 Jetlerson
~ ~ WB
- - Engineera
~ N 811 Jeiterson
~
uunues ~
N. 811 Jefferson = ' . .
, - Plan Rsvlear/Fln Preventlon
~ N 811 JeNereon ~
• - _ _ . .
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Otlror (SEPA/Crltket Matertal/ete.) y
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~ Fmet Tralc/SQealai tnsaseiton InfarnteUan
Project Representative r Phone
Address ,
1 certlfy that 1 have examine0 thia application and state ttiat the lntormatlon aontatned in it and aubm(ited
by melor my agent to oomplle eald applicatlon Is true and correct.
Slgnature- Oate
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